HospitalInspections.org

Based on observation, document review, and interview, the facility did not ensure that staff followed the facility's policy for safeguarding medications.

Findings:

During a tour of the Neurological Unit on 03/27/2019 at approximately 2:40 PM, it was observed that a medication cart was left unlocked and unattended in a patient's room. Another medication cart was unattended in the corridor. One draw was unlocked and the draw contained syringes and hypodermic needles.

Review of policy titled "Medication Policy: General Rules and Safeguards," stated: "Medication cart should not be left unattended when unlocked. The cart should be kept within view or locked when passing medications."

These findings were discussed with Staff I, RN, Psychiatry Director and Staff J, RN Assistant Head Nurse, who were present during the tour.

Based on medical record review, document review and interview, in one (1) of three (3) medical records reviewed, it was identified there was no documented evidence that the Physician or Nurse Midwife conducted ongoing pelvic exams and monitoring of a patient during active labor. (Patient #1)

Findings include:

Review of the medical record for Patient # 1 revealed: a 24 year old female at 39 weeks gestation arrived at the Labor and Delivery Unit on 1/29/19 at 2:34 PM with a chief complaint of contractions. The patient was admitted at 3:50 PM for induction of labor (IOL).

On 1/29/19 at 3:15 PM, physician history and physical documented "Fetal heart (FHT) 140, presentation cephalic, dilation 3cm, effacement 80%....."

Approximately (4) hours later at 7:15 PM, a Certified Nurse Midwife (CNM), Staff E, documented: Pelvic exam cervix 3cm, 80% effaced, station -3, fetal heart rate 140bmp."

At 9:10 PM, the attending physician documented the pelvic exam, and at 9:34 PM, a CNM, Staff S, documented a vaginal exam as, "dilation 2, effacement 70%, cervical mid-position method-digital."

On 1/30/19 at 9:23 AM, the Attending Obstetrician documented " uneventful normal spontaneous vaginal delivery of a live born female fetus delivered over intact perineum....mother and baby bonding well at 8:11 AM on 1/30/19.


There was no documented evidence of a provider monitoring or vaginal exam, from 9:35 PM on 1/29/19 until approximately 8:11 AM, 1/30/19, when a vaginal delivery was documented (approximately 12 hours).


Review of the facility's Policy titled "Admission and Management of the Patient in Labor," last revised 12/17 states:
9. "Physicians and Nurse Mid-wife will be responsible for each vaginal exam. The findings of pelvic exam (cervical dilatation, effacement, presenting part) must be documented in the electronic medical record (EME) .
19. "All vaginal exams done by the provider must be documented."
21. "Complete all documentation in the Medical Record."

The policy does not state the frequency for provider vaginal exams and documentation.

During interview on 3/29/19 at 1:19 pm with Staff F, Certified Nurse Midwife, she acknowledged the findings.

Based on medical record review, document review and interview, in one (1) of three (3) medical records reviewed, there was no documented evidence that the nursing staff provided ongoing fetal assessment of a patient in labor, as per facility's policy. (Patient #1)

Findings include:

Review of the facility's Policy titled "Admission and Management of the Patient in Labor," last revised 12/17 states:
6. "Fetal heart rate and contractions (frequency, duration, intensity and resting tone will be assessed and documented every 30 minutes or more frequently based on the stage of labor or the fetal status.
First Stage:
Latent phase - every 1/2 hour
Active phase - every 15 minutes
Second Stage:
Every 15 minutes until ready for delivery.
21. Complete all documentation in the Medical Record."

Review of the medical record for Patient # 1 revealed : a 24 year old female at 39 weeks gestation arrived in the Labor and Delivery Unit on 1/29/19 at 2:34 PM, with a chief complaint of contractions. The patient was admitted at 3:50 PM for induction of labor (IOL).

At 3:18 PM on 1/29/19 through 7:30 AM on 1/30/19, the nurses documented assessment of the fetal heart rate and uterine contractions approximately every 30 minutes. There is documentation by the RN of the patient's status post normal vaginal delivery of a baby girl at 8:11 AM , on 1/30/19.
There is no documented evidence of fetal assessment every 15 minutes during active labor and until the patient was ready for delivery.

During interview on 3/29/19 at 1:19 PM with Staff F, Certified Nurse Midwife she acknowledged the findings. Staff F stated sometimes staff may get busy and not hit the enter key, and the information is not documented.